A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's arms.
Administer a muscle relaxant.
Insert a tongue blade.
The Correct Answer is A
A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Can be a result of an early bowel obstruction. Hyperactive bowel sounds are characterized by loud, high-pitched, and frequent gurgling or rushing noises. They occur when there is increased intestinal motility, which can be seen in conditions such as gastroenteritis, diarrhea, or the early stages of a mechanical bowel obstruction. As the obstruction progresses, bowel sounds may become hypoactive or absent.
B. No sounds heard after listening for 3 to 5 min. This finding indicates absent bowel sounds, not hyperactive ones. Absent bowel sounds suggest complete bowel obstruction, paralytic ileus, or peritonitis and require immediate medical evaluation.
C. Sounds are soft and at a rate of 1/min. Hypoactive bowel sounds, rather than hyperactive ones, are characterized by infrequent, soft, or sluggish sounds occurring at a rate of less than 5 sounds per minute. Hypoactive bowel sounds are often associated with postoperative recovery, peritonitis, or late-stage bowel obstruction.
D. Indicates decreased motility. Hyperactive bowel sounds indicate increased, not decreased, intestinal motility. Decreased motility is associated with hypoactive or absent bowel sounds, which can occur due to conditions such as ileus, bowel obstruction, or the effects of certain medications, including opioids.
Correct Answer is B
Explanation
A. Place the client in a room with a high-efficiency particulate air (HEPA) filter. HEPA filtration is used for airborne precautions, such as tuberculosis. MRSA is transmitted through direct contact, so a private room or cohorting with another MRSA-positive client is sufficient.
B. Don gloves prior to assisting the client with brushing their teeth. MRSA is primarily spread via direct contact with infected wounds, secretions, or contaminated surfaces. Wearing gloves when providing personal care helps prevent transmission.
C. Ensure that the negative air pressure is active for the client's room. Negative pressure rooms are necessary for airborne pathogens like tuberculosis or measles. MRSA does not require airborne precautions, so this is not needed.
D. Have the client wear a mask when they are out of their room. A mask is only required if MRSA is present in the respiratory tract and the client has a productive cough. Standard contact precautions, such as hand hygiene and personal protective equipment, are the primary infection control measures.
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